GW1--00048_Well Construction - GW1_20231218

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: • •
1 14.WATER ZONES
Well Contractor Name FROM , TO , DESCRIPTION
1.5 S ft 18 ft. / 4 Of f
3 b`t I ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(tor multi-cased wells)OR LINER(if ap licable)
K. \..1 FROM TO DIAMETER THICKNESS MATERIAL
F�I/I S.r2l(`5 W��lt l�{ V�G. l•t-ft. fL 6 L! 1 in. d Dot() I P1r'l:-d
Company Name
.16.iNNER CASING OR TUBiNG'(geothermal closed-loop) .
2.Well Construction Permit#: 3`7 2 5 S FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft I in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) iigResidential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: .. _ 0 ft 3
2 ft. ezvyk,e..�� p(OtA.,(t„d`Monitoring ❑Recovery ft. ft �A _',❑
Injection Well: 3a O �� 4ll�t Q x�,- vy
ft ft. i
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop),,, ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrnck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. l LO ft. -D /D�
-in _.
4.Date Well(s)Completed: (► L--r I .3 Well ID# 3-1 g5-28 �u -ft. SO ;tt -5 t'l:kaL�Lt t-of a U t
5a.Well Location: _. - 5) ft 6S�- ft. G� t�Dt � c
U --
1Fa.C'G Sul\o r__IL is' ft 7$-- " i �sr°,i( 7ciy
Facility/Owner Name - FacilitylD#(ifapplicable) - '75.-R' Acts'ft. 70 1 I\ Q el�J RJ
ft. it ✓
So 5-5- Lurm A-ieva-I-t e_i L O k-m,;,--cP t ',is-vs-
Physical Address,City,add Zip ft' ft
0.Sf1'-t- lke_, O t{-- - b 3 D( 5 9( L 21.REMARKS I --- --
•
,County Parcel Identification No.(PIN)
r.
- < .:--3-.•'Pi..:.i id'k'-.a.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C
(if well field,one IaUlong is sufficient) 22.CLC
cation O L. 1 8 2 -3
31g, L1 k )� N riSC-tkk. �4)-1 - W 4 > ' h�6.1s(are)thewell(s): Permanent or ❑Temporarye ed ell•�n�• tor °b�*'" �'LDate
By signing this form,I hereby certify t at the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ,No 15A MAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remark section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0-5-
(ft.)
For multiple wells list all depths if different(example-3@200'and 2 a( l00') Submit this GW-1 within 30 dais of well completion per the following:
d Z (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: o Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing..use""+c . .-
11.Borehole diameter: b (in.) 24b.For injection Wells: Copy to;DWR,Underground Injection Control(iUC)
Program,1636 MSC,Raleigh,NC;27699-1636
12.Well construction method: A-/,9-- Q 6779 R4 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of.the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
/ t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) C 0 •Method of test: \
I �/� e✓ II
13b.Disinfection type..Y )oc4vo( f _-' Amount: ( 6�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018